This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching”) of my teeth.

Description of the Procedure

In-office tooth whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. During the procedure, the whitening gel will be applied to my teeth for two to four, 15-minute sessions. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e., my lips, gums, cheeks, and tongue) will be covered to ensure they are not exposed to the gel. Lip balm may also be applied as needed, and I will be provided eye protection. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper front teeth will be assessed and recorded.

Alternative Treatments

I understand I may decide not to have any treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:

• Whitening Toothpaste/Gels
• Take-Home Whitening Kits

Cost

I understand that the cost of my treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my treatment.

Risks of Treatment

I also understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from whitening treatments, and significant whitening can be achieved in most cases. I understand that whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers, or porcelain, composite, or other restorative materials, and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments, or may not whiten at all. I understand that teeth with many fillings, cavities, chips, or cracks may not lighten and are usually best treated with other non-bleaching alternatives. I understand that provisional or temporaries made from acrylics may become discolored.

I understand that treatment is not recommended for patients with known sensitivity to resins, peroxides, or glycols.

I understand that the results of my Treatment cannot be guaranteed.

I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:

• Tooth Sensitivity/Pain - During the first 24 hours after treatment, many patients can experience tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and occlusal wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after treatment.
• Gum/Lip/Cheek Inflammation - Whitening may cause inflammation of your gums (Chemical burn), lips, or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel. The inflammation is usually temporary and will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel.
• Dry/Chapped Lips - The treatment involves two to four 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by the application of lip balm, petroleum jelly, or Vitamin E cream.
• Cavities or Leaking Fillings - Most dental whitening is indicated for the external surfaces of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing the gel to penetrate the tooth, significant pain and damage to the tooth could happen. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings re-done before undergoing the treatment.
• Cervical Abrasion/Erosion - These are conditions that affect the root surfaces of the teeth when the gums recede and they are characterized by grooves, notches, and/or depressions that appear darker than the rest of the teeth, where the teeth meet the gums. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth causing sensitivity, pain, and possible damage to the nerve. I understand that if my teeth have these conditions, I should not undergo the treatment.
• Root Resorption - This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.
• Relapse - After the treatment, it is natural for the teeth that underwent the whitening procedure to regress somewhat in their shading. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves the use of a home bleaching kit or redoing the treatment. I understand that the results of the treatment are not intended to be permanent, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include coffee, tea, beverages, colored food items, and ALL tobacco products. I understand that there are other substances that could discolor my teeth which I should avoid during the first 48 hours after treatment. If I have any questions regarding any such substance, I understand that I can discuss its stain potential with my dentist.

The safety, efficacy, potential complications, and risks of treatment can be explained to me by my dentist, and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of treatment, the list of complications in this form is incomplete.

The basic procedures of treatment and the advantages and disadvantages, risks, and known possible complications of alternative treatments have been explained to me by my dentist, and my dentist has answered all my questions to my satisfaction.

In signing this informed consent I am stating I have read this informed consent (or it has been read to me) I fully understand it and the possible risks, complications, and benefits that can result from the treatment, and that I agree to undergo the treatment as described by my dentist.

Tooth Number:

Alternatives to the above treatment